Mr. SKB

70-year-old male, known case of hypertension with past history of CABG (LIMA-LAD) done in 1997 and PCI to LCX done in 2013 presented with Unstable angina. Angiogram done at outside hospital showed Native 3 vessel CAD, patent LIMA-LAD graft and patent LCX stent, heavily calcified and tight lesion in RCA- PCI was attempted elsewhere and failed due to unyielding calcific lesion. Clinical examination was unremarkable.

ECG showed sinus rhythm, ST depression and T wave inversions in inferolateral leads.

Coronary angiogram revealed tram track calcific RCA with tight lesion of 95% severity in proximal RCA.
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RCA was engaged with 7 F AL 0.75 guiding catheter and wired with 014 Sion Blue wire, predilatation of the lesion was done with Mini Trek 1.2 x 15 mm balloon at 18 atm followed by 2.0 x 15 mm Across HP balloon at 18 atm and 3.0 x 15 mm Across HP balloon at 20 atm. Intravascular ultrasound showed long segment 360' calcium. Intravascular lithotripsy was done using 3.0 x 12 mm ShockWave balloon, total of 8 pulses used and still there was a residual lesion which was cracked with 3 x 10 mm OPN noncompliant balloon at 35 atm. Distal-mid RCA was stented with 3.5 x 28 mm Promus Premier DES and it was overlapped with 3.5 x 38 mm Xience Prime DES, postdilated with 3.5 x 8 mm Across HP balloon at 20 atm. Final IVUS showed no edge dissection and well apposed stent.
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Calcium is the enemy of interventional cardiologists and it is considered as the Achilles heel of percutaneous coronary intervention. Adequate and appropriate calcium debulking prior to stent implantation is essential for optimal results. Intravascular lithotripsy is a novel technology and is a useful calcium modifying tool with very low complications rate.